Background: Syncope is one of the most distressing symptoms in cardiologic practice and an uncommon symptom of the coronary disease. Syncope accompanied with chest pain in absence of rhythm and conduction disorders may suggest lesion of the principal trunk of the left coronary artery. (1, 2)

Case Report: 49-years-old patient came to the cardiology unit because of chest discomfort lasting for the past 2 months. When walking normally, he feels chest discomfort propagating into both arms, occasionally accompanied with syncope lasting for 3-6 minutes. His cardiovascular risk factors are hypertension and smoking. Family history is negative for cardiovascular diseases. Previously, he underwent neurologic evaluation: carotid Doppler sonography and cervical spine X-ray were performed. Electrocardiography at rest was normal. He brought his 24 h Holter ECG showing regular sinus rhythm, rare isolated VESs following T wave (a total of 85 during 24 hours) and rare SVESs. At heart rate of 110/min, there was a 3 mm ST depression in Ch2 and Ch3. No malignant rhythm disturbances or pauses longer than 2 sec were recorded. Heart ultrasound showed normal aortic and left atrial diameter. Left ventricle has normal internal dimensions, wall thickness and no visible segment dysfunctions at the time of the exam. Estimated EF was 75%. After 2 minutes at first level of load, exercise test showed chest pain and 2 mm horizontal ST depression in D1, aVL and V4-V6 with 1 mm elevation in aVR. Emergency coronarography was scheduled and during immediate preparation for it, patient had cardiac arrest. Cardiopulmonary resuscitation measures were administered and the coronarography showed thrombosis of the principal trunk of the left coronary artery. A single stent was implanted ensuring optimal coronary flow.

Conclusion: The presence of syncope in this patient without any documented arrhythmia or structural heart disease and accompanied with chest pain suggested high grade coronary stenosis and required prompt diagnostics. The case may be informative because syncope was an initial symptom of the coronary disease which drove patient to seek medical assistance.